First Rib Resection Research Articles

Acute Paget–Schroetter Syndrome: Does the First Rib Routinely Need to Be Removed after Thrombolysis?

Most clinicians feel that treatment for patients with acute primary axillosubclavian vein thrombosis ("effort thrombosis") is catheter-directed thrombolysis followed by thoracic outlet decompression. Several investigators feel that first rib resection (FRR) is not indicated in every case. No randomized data exist to answer this question. A MEDLINE search was done using the terms "Paget-Schroetter syndrome," "upper extremity DVT," "first rib resection," "effort thrombosis," and "primary upper extremity thrombosis," with thrombolysis used as an "AND" term. We also specifically explored references cited to support either side of this argument in the past. Analysis was limited to patients aged 18years or older with symptoms of 14-day duration or less undergoing thrombolysis for primary axillosubclavian vein thrombosis. Those studies that did not report follow-up, duplicate series from the same institution, and those in which patients were stented were excluded. Results were analyzed on an intent-to-treat basis, with groups assigned according to each authors' prospectively described algorithm. Twelve series were included. Patients were divided into 3 groups according to treatment after thrombolysis: FRR (448 patients), FRR plus endovenous balloon venoplasty (FRR+PLASTY; 68 patients), and those with no further intervention after thrombolysis (rib not removed; 168 patients). Symptom relief at last follow-up was significantly more likely in the FRR (95%) and FRR+PLASTY (93%) groups than in the rib not removed (54%) group (both <0.0001) as was patency (98%, 86%, and 48%, respectively; both <0.0001 vs. rib not removed). More than 40% of patients in the rib not removed group eventually required rib resection for recurrent symptoms. No differences in symptom-free rates were seen when comparing FRR with FRR+PLASTY. In patients with acute effort thrombosis who undergo thrombolysis, permanent symptom relief and long-term patency are more likely to be achieved in patients who undergo FRR with or without endovenous balloon venoplasty than those whose rib is left intact.

A Decade of Excellent Outcomes after Surgical Intervention in 538 Patients with Thoracic Outlet Syndrome

Our aim was to evaluate the outcomes of patients who underwent first rib resection (FRR) for all 3 forms of thoracic outlet syndrome (TOS) during a period of 10 years. Patients treated with FRR from August 2003 through July 2013 were retrospectively reviewed using a prospectively maintained database. Five hundred and thirty-eight patients underwent 594 FRRs for indications of neurogenic (n = 308 [52%]), venous (n = 261 [44%]), and arterial (n = 25 [4%]) TOS. Fifty-six (9.4%) patients had bilateral FRR. Fifty-two (8.8%) patients had cervical ribs. Three hundred and ninety-eight (67%) FRRs were performed on female patients, with a mean age of 33 years (range 10 to 71 years). Three hundred and forty (57%) were right-sided procedures. Seventy-five children (aged 18 years or younger) underwent FRRs; 25 during the first 5 years and 50 during the second 5 years. When comparing the second 5-year period with the first 5-year period, more patients had venous TOS (48% vs 37%; p < 0.02); fewer patients had neurogenic TOS (48% vs 58%; p < 0.05), and improved or fully resolved symptoms increased from 93% to 96%. Complications included 2 vein injuries, 2 hemothoraces, 4 hematomas, 138 pneumothoraces (23%), and 8 (1.3%) wound infections. Mean length of stay was 1 day. Excellent results were seen in this surgical series of neurogenic, venous, and arterial TOS due to appropriate selection of neurogenic patients, use of a standard protocol for venous patients, and expedient intervention in arterial patients. There is an increasing role for surgical intervention in children.

Regrown First Rib in Patients with Recurrent Thoracic Outlet Syndrome

Recurrent symptoms of thoracic outlet syndrome (TOS) after first rib resection have varying etiologies. Regrowth of a first rib is a rare event. Recurrent symptoms in the presence of a regrown rib strongly suggest a causal relationship. We report our experience with recurrent symptoms of TOS and regrown first ribs. We identified patients with recurrent TOS symptoms and regrown first ribs presented between 1995 and 2012. Details regarding their presentation, evaluation, and treatment were gathered. Eight patients (6 women and 2 men) presenting with recurrent TOS symptoms and regrown first ribs underwent 10 decompression surgeries. Prior surgeries included supraclavicular first rib resection (5), transaxillary first rib resection (5), scalenectomy (5), cervical rib resection (1). The average period between initial surgery and reoperation was 4.7 years. Average age at current presentation was 40.8 years (range 29-52). All patients (8) represented with neurogenic symptoms and 1 patient with concomitant venous TOS symptoms. Presenting symptoms included pain (8), numbness and tingling (7), weakness (6), headache (2), and venous congestion (3). Initial treatment included physical therapy in all. Preoperative assessment included chest X-rays (8), magnetic resonance imaging (7), electrodiagnostic studies (8), venography (2), and anterior scalene muscle block (2). Surgical approach included transaxillary resection of the regrown first rib (10), neurolysis of brachial plexus (10), scalenectomy (5), and lysis of subclavian vein (1). After an average follow-up of 10.8 months, resolution of symptoms included 4 complete and 4 partial. Regrowth of the first rib is a rare event. There is a concordance between a regrown rib and TOS symptoms. Patients presenting with recurrent TOS symptoms and a regrown first rib have a high probability of improvement with resection of the regrown rib.

Resection of the entire first rib for fibrous dysplasia using a combined posterior-transmanubrial approach

A 27-year-old woman presented with pain of the left anterior chest of 2-year duration. Chest X-ray revealed a mass in the upper-left lung field and chest computed tomography (CT) a 6-cm first-rib tumor. CT-guided biopsy was performed and the tumor diagnosed as fibrous dysplasia. Because of continued pain, surgery was deemed necessary. Surgery began with the use of the posterior approach in the prone position to expose the first thoracic vertebra and detach the first rib at the costotransverse joint. After transitioning to the spine position, the transmanubrial approach was used to resect the tumor en bloc with the left first rib. Histological examination revealed the tumor to be fibrous dysplasia. Postoperative recovery was uneventful. The outcomes of this case suggest that the combined posterior-transmanubrial approach described here is a safe, successful approach for first-rib resection of a space-occupying tumor that yields good cosmetic results.

A Woman Post Scalenectomy and First-Rib Resection With Dilated Vertebral Venous Plexus and a Facial Rash

Background Sickle cell disease (SCD) is found in many ethnic groups, with the highest prevalence of heterozygote carriers (sickle cell trait [SCT]) in African Americans. SCT is associated with an increased risk of fatal exertional heat illness, renal papillary necrosis, and splenic infarction. Since 2006, all infants born in the United States are required to be screened for hemoglobinopathies as part of newborn screening (NBS). In 2010, as part of a legal settlement, the National Collegiate Athletic Association (NCAA) implemented SCT screening in division I athletes.

Robotic En Bloc First-Rib Resection for Paget-Schroetter Disease, a Form of Thoracic Outlet Syndrome Technique and Initial Results

First-rib resection is a key component of the treatment of Paget-Schroetter disease. There are many controversies regarding the management of this disease. We report a safe, effective, minimally invasive robotic transthoracic approach for resection of the first rib. Over an 8-month period, five patients underwent robotic first-rib resection. Preoperative assessment included physical examination and bilateral venous angiography. On a thoracoscopic platform using three 2-cm incisions and one 1-cm incision, the robot was used to dissect the first rib and divide the scalene muscles. Success of the first-rib resection was assessed by postoperative venous angiography. There were four men and one woman. Mean age was 34.6 ± 10 years. Mean operative time was 195 ± 24.6 minutes. There were no complications and no mortality. All patients had a patent subclavian vein on the postoperative venogram and were anticoagulated with warfarin for 3 months. At a median follow-up of 12 months, all patients had an open subclavian vein for a patency rate of 100%. Robotic thoracoscopic first-rib resection represents a feasible minimally invasive approach to en bloc resection of the first rib. This technique minimizes the risk of neurovascular complications that are associated with conventional techniques.

Spectrum of Thoracic Outlet Syndrome Presentation in Adolescents

To study the outcomes of children with thoracic outlet syndrome (TOS) treated surgically with transaxillary first-rib resection and scalenectomy (FRRS). A retrospective database review. The Johns Hopkins Medical Institutions. Patients 18 years or younger who had undergone FRRS. All patients underwent FRRS. Patients with venous TOS underwent venography 2 weeks postoperatively. Main Outcomes Measures For patients with venous TOS, good outcomes included patent subclavian veins. For patients with neurogenic and arterial TOS, good outcomes included relief of pain and discomfort. Thirty-five adolescents, including 14 male and 21 female patients, presented with TOS. Of these, 18 had venous symptoms, 9 had neurogenic symptoms, and 8 had arterial symptoms. Seventeen of the 18 patients with venous TOS had thrombosis. At postoperative venography, 13 patients required dilation of a stenotic vein, 2 had patent veins, and 2 had chronically occluded veins. All 18 patients had patent veins, but 1 had persistent ipsilateral neurogenic symptoms. Physical therapy before FRRS had failed in all 9 patients with neurogenic TOS. Five of the 8 patients with arterial TOS presented with abnormal ribs. Two had episodes of embolization, and 1 had an occluded radial artery. None had an axillosubclavian aneurysm. All 8 patients underwent FRRS; 3 also required removal of the fused cervical rib. All 35 patients had a favorable follow-up period. Adolescents present more frequently with venous and arterial TOS than do adults. However, in nearly all adolescent patients, treatment with FRRS leads to a rapid return to full activity.

Surgical intervention for thoracic outlet syndrome improves patient's quality of life

To assess long-term quality of life outcomes in patients following transaxillary first-rib resection and scalenectomy for thoracic outlet syndrome (TOS). This was a prospective observational study using the Short-Form 12 (SF-12) and Disability of Arm, Hand, and Shoulder (DASH) instruments between February 2005 and March 2008 in patients with TOS presenting to an academic medical center for preoperative surgical evaluation after failing physical therapy protocol. Surveys were conducted preoperatively and then again at 3, 6, 12, 18, and 24 months after surgery. Longitudinal data analysis was performed with population-averaged models using generalized estimating equations (GEE) method for average rate of recovery. Kaplan-Meier method was used to analyze time to return to work. A total of 70 out of 105 eligible patients (66.7%) completed the study protocol (44 neurogenic; 26 venous), returning 243 valid SF-12 surveys (162 neurogenic; 81 venous) and 188 valid DASH surveys (124 neurogenic; 64 venous). Half (50%) of the neurogenic patients and 77% of the venous patients returned to full-time work or activity within the study follow-up, with half of them doing so by 4 months and 75% of them by 5 months. There was no statistically significant difference in return to work between the neurogenic or venous patients. Neurogenic patients had baseline SF-12 Physical Component Scores (PCS) similar to chronic heart failure patients and were significantly worse than venous patients (33.8 vs 43.6, P < .001). In contrast, no difference existed in Mental Component Scores (MCS) (44.5 vs 43.5, P = .78). In follow-up, on average, PCS scores for neurogenic patients improved 0.24 points (P < .001) and MCS scores improved 0.15 points per month (P = .01); while PCS scores for venous patients improved 0.40 points (P = .004) and MCS scores improved 0.55 points per month (P < .001). Additionally, neurogenic patients had baseline DASH scores that were similar to patients with rotator cuff tears, and they were also significantly worse than venous patients (50.2 vs 25.0, P < .001). DASH scores, on average, also improved 0.85 points (P < .001) for neurogenic patients and 0.81 points (P < .001) for venous patients per month. The use of the SF-12 and DASH instruments in patients with TOS demonstrated significant improvement in patients postoperatively. Venous TOS patients typically improved both physical and mental scores in shorter periods of time than their neurogenic counterparts. Neurogenic and venous TOS patients returned to full-time work/activity within the same length of time postoperatively. However, neurogenic patients required more secondary interventions. We conclude that in appropriately selected patients with either neurogenic or venous TOS, surgical intervention can improve their quality of life over time.

Long-term thrombotic recurrence after nonoperative management of Paget-Schroetter syndrome

The purpose of this study was to determine the clinical predictors associated with long-term thrombotic recurrences necessitating surgical intervention after initial success with nonoperative management of patients with primary subclavian vein thrombosis. Sixty-four patients treated for Paget-Schroetter syndrome from 1996 to 2005 at our institution were reviewed. The standardized protocol for treatment includes catheter-directed thrombolysis, a short period of anticoagulation, and selective surgical decompression for patients with persistent symptoms. First-rib resection was performed in 29 patients (45%) within the first 3 months, with a success rate of 93%. The remaining 35 patients (55%) were treated nonoperatively and constitute this study's population. Of the 35 patients with successful nonoperative management, 8 (23%) developed recurrent thrombotic events of the same extremity at a mean follow-up time of 13 months after thrombolysis (range, 6-33 months). These eight patients subsequently underwent first-rib resection with a 100% success rate without further sequelae at a mean follow-up time of 51 months (range, 2-103 months). The other 27 patients remained symptom free at a mean follow-up interval of 55 months (range, 10-110 months). Bivariate analyses determined that the use of a stent during the initial thrombolysis was associated with thrombotic recurrence (P = .05). The recurrence group was also significantly younger than the asymptomatic group (22 vs 36 years; P = .01). Sex, being a competitive athlete, a history of trauma, whether the dominant arm was affected, time of delay to lysis, initial clot burden, response to original lysis, use of adjunctive balloons or mechanical thrombectomy devices, residual stenosis on venography, length of time on warfarin, and patency of the vein on follow-up duplex examination were all characteristics not associated with long-term recurrence after nonoperative management. Conservative nonoperative management of primary subclavian vein thrombosis can be successfully used with acceptable long-term results. A younger age (<28 years old) and the use of a stent during initial thrombolysis are factors associated with long-term recurrent thrombosis. Younger patients should be offered early surgical decompression, and the use of stents without thoracic outlet decompression is not indicated.

Reply

We appreciate Dr Molina’s interest in our article,1Schneider D.B. Dimuzio P.J. Martin N.D. Gordon R.L. Wilson M.W. Laberge J.M. et al.Combination treatment of venous thoracic outlet syndrome open surgical decompression and intraoperative angioplasty.J Vasc Surg. 2004; 40: 599-603Abstract Full Text Full Text PDF PubMed Scopus (95) Google Scholar and we recognize his contributions to the literature regarding the treatment of venous thoracic outlet syndrome. We agree with Dr Molina that claviculectomy is unnecessary and that subclavian vein decompression may be performed through an infraclavicular incision. The last two patients in our recent series underwent decompression through an infraclavicular incision, and this is now our preferred approach.1Schneider D.B. Dimuzio P.J. Martin N.D. Gordon R.L. Wilson M.W. Laberge J.M. et al.Combination treatment of venous thoracic outlet syndrome open surgical decompression and intraoperative angioplasty.J Vasc Surg. 2004; 40: 599-603Abstract Full Text Full Text PDF PubMed Scopus (95) Google Scholar However, we do not agree that vein patch angioplasty is necessary to achieve durable subclavian vein patency and that percutaneous subclavian vein angioplasty after surgical decompression “will lead invariably to more fibrosis,” as Dr Molina contends in his letter. To the contrary, our results suggest that surgical decompression followed by percutaneous angioplasty is safe and effective, resulting in 92% 1-year objective primary patency.1Schneider D.B. Dimuzio P.J. Martin N.D. Gordon R.L. Wilson M.W. Laberge J.M. et al.Combination treatment of venous thoracic outlet syndrome open surgical decompression and intraoperative angioplasty.J Vasc Surg. 2004; 40: 599-603Abstract Full Text Full Text PDF PubMed Scopus (95) Google Scholar Rethrombosis occurred in two patients in our series and was an early postoperative event likely related to extensive venous disease present at the time of treatment and not to the later development of fibrosis. Dr Molina’s own experience2Molina J.E. Surgery for effort thrombosis of the subclavian vein.J Thorac Cardiovasc Surg. 1992; 103: 341-346PubMed Google Scholar, 3Molina J.E. Need for emergency treatment in subclavian vein effort thrombosis.J Am Coll Surg. 1995; 181: 414-420PubMed Google Scholar with open surgical subclavian vein reconstruction for lesions longer than 2.5 or 2 cm with patency rates of 25% and 37.5%, respectively, indicates that patency is arguably more a function of lesion extent and chronicity than of the technique used to treat a residual subclavian vein stenosis. Finally, it seems that Dr Molina has successfully used percutaneous angioplasty to treat residual subclavian vein stenosis after both surgical subclavian vein decompression2Molina J.E. Surgery for effort thrombosis of the subclavian vein.J Thorac Cardiovasc Surg. 1992; 103: 341-346PubMed Google Scholar and surgical subclavian vein decompression with vein patch angioplasty, with durable success.3Molina J.E. Need for emergency treatment in subclavian vein effort thrombosis.J Am Coll Surg. 1995; 181: 414-420PubMed Google Scholar Indeed, our similar favorable experiences with postoperative subclavian vein angioplasty led us to adopt our current approach of subclavian vein decompression and intraoperative angioplasty, which we believe to be the optimal treatment for venous thoracic outlet syndrome. Regarding “Combination treatment of venous thoracic outlet syndrome: Open surgical decompression and intraoperative angioplasty”Journal of Vascular SurgeryVol. 42Issue 3PreviewI read with interest the work by Schneider et al titled “Combination Treatment of Venous Thoracic Outlet Syndrome: Open Surgical Decompression and Intraoperative Angioplasty.”1 The authors report the treatment of 25 patients with first-rib resection and intraoperative balloon angioplasty of the subclavian vein. In contrast to this approach, I prefer decompressing the subclavian vein through a subclavicular incision and enlarging the caliber of the vein with a vein patch.2-4 Our approach also involves a single operation and has resulted in 100% patency without the need for venography or balloon angioplasty in the operating room. Full-Text PDF Open Archive

Role of first rib stump length in recurrent neurogenic thoracic outlet syndrome

We read with great interest the article by Ambrad-Chalela et al [1] in which the investigators reported their experience with recurrent neurogenic thoracic outlet syndrome (TOS). They identified just 1 case (6%) in which an incomplete first-rib resection was responsible for the symptom recurrence and stated that incomplete excision of first rib is an occasional cause of TOS recurrence. Conversely, in our experience on 118 patients who had transaxillary first-rib resection for TOS, a long first-rib posterior stump—shown by routine follow-up chest x-ray films—was responsible for TOS recurrence in 20 of 25 cases (80%) [2].

Combination treatment of venous thoracic outlet syndrome: Open surgical decompression and intraoperative angioplasty

Residual subclavian vein stenosis after thoracic outlet decompression in patients with venous thoracic outlet syndrome is often treated with postoperative percutaneous angioplasty (PTA). However, interval recurrent thrombosis before postoperative angioplasty is performed can be a vexing problem. Therefore we initiated a prospective trial at 2 referral institutions to evaluate the safety and efficacy of combined thoracic outlet decompression with intraoperative PTA performed in 1 stage. Over 3 years 25 consecutive patients (16 women, 9 men; median age, 30 years) underwent treatment for venous thoracic outlet syndrome with a standard protocol at 2 institutions. Twenty-one patients (84%) underwent preoperative thrombolysis to treat axillosubclavian vein thrombosis. First-rib resection was performed through combined supraclavicular and infraclavicular incisions. Intraoperative venography and subclavian vein PTA were performed through a percutaneous basilic vein approach. Postoperative anticoagulation therapy was not used routinely. Venous duplex ultrasound scanning was performed postoperatively and at 1, 6, and 12 months. Intraoperative venography enabled identification of residual subclavian vein stenosis in 16 patients (64%), and all underwent intraoperative PTA with 100% technical success. Postoperative duplex scans documented subclavian vein patency in 23 patients (92%). Complications included subclavian vein recurrent thrombosis in 2 patients (8%), and both underwent percutaneous mechanical thrombectomy, with restoration of patency in 1 patient. One-year primary and secondary patency rates were 92% and 96%, respectively, at life-table analysis. Residual subclavian vein stenosis after operative thoracic outlet decompression is common in patients with venous thoracic outlet syndrome. Combination treatment with surgical thoracic outlet decompression and intraoperative PTA is a safe and effective means for identifying and treating residual subclavian vein stenosis. Moreover, intraoperative PTA may reduce the incidence of postoperative recurrent thrombosis and eliminate the need for venous stent placement or open venous repair.

Thoracic Outlet Syndrome Surgery: Long-Term Functional Results

The treatment of thoracic outlet syndrome (TOS) is controversial and long-term results are poorly documented. This retrospective study was carried out to assess clinical outcome 2 years after TOS surgery and to determine predictive factors of outcome. Between 1979 and 1999, 155 patients underwent TOS surgery. Of these patients, 140 (90.3%) had a minimum follow-up of 2 years. Thirty-six (25.7%) patients underwent bilateral procedures. A total of 176 procedures were reviewed and served as a basis for study. Presenting symptoms were neurologic in 15 cases (8.5%), arm or hand ischemia occurred in 38 cases (21.6%), and venous compression or thrombosis in 27 cases (15.4%). In 96 cases (54.5%), symptoms were mixed. A transaxillary approach (107 cases) was chosen to address venous symptoms and minor arterial dysfunction. A supraclavicular approach (69 cases) was used when there were large abnormal bony structures, neurologic symptoms, and/or severe limb ischemia. The first rib was resected either extensively from its neck to the sternal attachment (54 cases) or partially, including the mid-rib and neck or the mid-rib and sternal attachment (121 cases), depending on symptoms, approach, and surgeon's choice. Whenever present, cervical ribs, anterior scalenus muscle, and various fibrous or muscular compressive structures were also removed. The 2-year functional outcome according to Derkash's classification was assessed by means of a phone survey. Pre-, per-, and immediate postoperative data were recorded and compared to functional outcomes. Mean follow-up was 7.5 A+/- 3.4 years (2a<euro>"19 years). Functional results were excellent, good, fair, and poor in 87 (49.4%), 61 (34.6%), 14 (8%),and 14 (8%) procedures respectively. Predictive factors of negative outcomes were acute ischemia ( p < 0.01), sensory or motor deficit ( p < 0.01), and poorly systematized neurological symptoms as presenting symptoms ( p < 0.05), and extended resection of the first rib ( p < 0.01) and severe postoperative complications ( p < 0.01). This series showed that the 2-year results of TOS surgery were satisfactory in the majority of cases. Patients suffering from poorly systematized neurological symptoms in the arm had poor results. This subset of patients should be denied surgery or at least informed that postoperative results might be disappointing. Partial first-rib resection and a careful technique avoiding postoperative complications were also factors in long-term success.

Recurrent neurogenic thoracic outlet syndrome

Background Although 90% of patients with neurogenic thoracic outlet syndrome (NTOS) experience “excellent” or “good” results after thoracic outlet decompression, recurrent symptoms may develop in certain patients. Methods This is a retrospective review of patients with NTOS who developed recurrent symptoms of upper extremity/shoulder/neck pain, weakness and limitation of motion at least 3 months after initial relief of symptoms by surgical decompression. Diagnostic procedures and outcomes of reoperative surgery were assessed. Results Among almost 500 patients undergoing initial successful thoracic outlet decompression for symptoms of NTOS during the last decade, 17 redeveloped classic NTOS symptoms (3 of them bilaterally) at intervals from 3 to 80 months (mean 18 months) after the initial operative procedure. Ultimate diagnoses included incomplete first-rib resection (n = 1), compression of the brachial plexus by an ectopic band (n = 1), persistent brachial plexus compression by an intact first (n = 2) or second (n = 1) rib, brachial plexus compression by the pectoralis minor tendon (n = 13) and adherent residual scalene muscle (n = 14). Anterior scalene muscle block was positive in 9 patients later found to have recurrent symptoms from adherent residual scalene muscle. Among these 20 cases of osseous or musculotendinous causes of recurrent NTOS, all had “excellent” or “good” results from repeat surgery to eliminate the underlying structural problem (removal of intact or residual rib, pectoralis minor tenotomy, brachial plexus neurolysis, or a combination of these). Conclusions Complete excision of cervical or first ribs and subtotal excision (instead of simple division) of the scalene muscles will decrease the incidence of recurrent NTOS. Pectoralis minor tenotomy should be considered part of complete thoracic outlet decompression. Anterior scalene muscle block accurately predicts outcome of reoperation for certain types of recurrent NTOS.

Recurrent neurogenic thoracic outlet syndrome

Background Although 90% of patients with neurogenic thoracic outlet syndrome (NTOS) experience “excellent” or “good” results after thoracic outlet decompression, recurrent symptoms may develop in certain patients. Methods This is a retrospective review of patients with NTOS who developed recurrent symptoms of upper extremity/shoulder/neck pain, weakness and limitation of motion at least 3 months after initial relief of symptoms by surgical decompression. Diagnostic procedures and outcomes of reoperative surgery were assessed. Results Among almost 500 patients undergoing initial successful thoracic outlet decompression for symptoms of NTOS during the last decade, 17 redeveloped classic NTOS symptoms (3 of them bilaterally) at intervals from 3 to 80 months (mean 18 months) after the initial operative procedure. Ultimate diagnoses included incomplete first-rib resection (n = 1), compression of the brachial plexus by an ectopic band (n = 1), persistent brachial plexus compression by an intact first (n = 2) or second (n = 1) rib, brachial plexus compression by the pectoralis minor tendon (n = 13) and adherent residual scalene muscle (n = 14). Anterior scalene muscle block was positive in 9 patients later found to have recurrent symptoms from adherent residual scalene muscle. Among these 20 cases of osseous or musculotendinous causes of recurrent NTOS, all had “excellent” or “good” results from repeat surgery to eliminate the underlying structural problem (removal of intact or residual rib, pectoralis minor tenotomy, brachial plexus neurolysis, or a combination of these). Conclusions Complete excision of cervical or first ribs and subtotal excision (instead of simple division) of the scalene muscles will decrease the incidence of recurrent NTOS. Pectoralis minor tenotomy should be considered part of complete thoracic outlet decompression. Anterior scalene muscle block accurately predicts outcome of reoperation for certain types of recurrent NTOS.

Thoracic outlet syndrome in a child—Transaxillary resection of anomalous first rib

Thoracic outlet syndrome (TOS) is extremely rare in children. Only several pediatric cases have been reported, and all presented with neurologic symptoms. The authors report on a 6-year-old boy with an asymptomatic left subclavian artery aneurysm caused by compression of the subclavian artery by an anomalous first rib with poststenotic aneurysmal dilatation. This was successfully managed by transaxillary resection of the anomalous rib. This represents the youngest reported case of TOS and the first description of a vascular manifestation of TOS in the pediatric population. Access to the costoscalene triangle utilizing a transaxillary approach was straightforward and afforded excellent exposure, even in a child. J Pediatr Surg 37:1220-1222. Copyright 2002, Elsevier Science (USA). All rights reserved.

Long-term Results of Venous Revascularization for Paget-Schroetter Syndrome in Athletes

The indications for surgical management of primary subclavian vein thrombosis are not agreed upon. This report describes our experience in the treatment of exertional thrombosis causing Paget-Schroetter syndrome in 10 athletes between 18 and 45 years of age. In seven patients urokinase was injected and this resulted in complete revascularization in three cases (42.9%). The remaining three patients were treated by anticoagulation using heparin with adjuvant Coumadin after resolution of thrombosis. Duplex ultrasonography and dynamic phlebography were performed to assess the results of drug treatment. Decompression of the thoracic outlet was performed secondarily using various techniques, including first-rib resection in 10 cases, scalenectomy in 9, and resection of a clavicular callus in 1 case. In six patients, persistent debilitating venous stasis required revascularization by axillojugular bypass in three cases, thrombectomy in two, and axillojugular anastomosis in one case. All patients were reexamined. Mean follow-up was 45 months. Symptomatic relief and vein patency was achieved in all cases. All patients were able to resume sports activity. In agreement with previous studies, our findings confirm the efficacy of immediate anticoagulation, thrombolysis, and complete decompression of the thoracic outlet. Should this approach fail to reestablish patency, axillosubclavian vein revascularization can provide good mid-term results.

Surgical intervention is not required for all patients with subclavian vein thrombosis

Purpose: The role of thoracic outlet decompression in the treatment of primary axillary-subclavian vein thrombosis remains controversial. The timing and indications for surgery are not well defined, and thoracic outlet procedures may be associated with infrequent, but significant, morbidity. We examined the outcomes of patients treated with or without surgery after the results of initial thrombolytic therapy and a short period of outpatient anticoagulation. Methods: Patients suspected of having a primary deep venous thrombosis underwent an urgent color-flow venous duplex ultrasound scan, followed by a venogram and catheter-directed thrombolysis. They were then converted from heparin to outpatient warfarin. Patients who remained asymptomatic received anticoagulants for 3 months. Patients who, at 4 weeks, had persistent symptoms of venous hypertension and positional obstruction of the subclavian vein, venous collaterals, or both demonstrated by means of venogram underwent thoracic outlet decompression and postoperative anticoagulation for 1 month. Results: Twenty-two patients were treated between June 1996 and June 1999. Of the 18 patients who received catheter-directed thrombolysis, complete patency was achieved in eight patients (44%), and partial patency was achieved in the remaining 10 patients (56%). Nine of 22 patients (41%) did not require surgery, and the remaining 13 patients underwent thoracic outlet decompression through a supraclavicular approach with scalenectomy, first-rib resection, and venolysis. Recurrent thrombosis developed in only one patient during the immediate period of anticoagulation. Eleven of 13 patients (85%) treated with surgery and eight of nine patients (89%) treated without surgery sustained durable relief of their symptoms and a return to their baseline level of physical activity. All patients who underwent surgery maintained their venous patency on follow-up duplex scanning imaging. Conclusion: Not all patients with primary axillary-subclavian vein thrombosis require surgical intervention. A period of observation while patients are receiving oral anticoagulation for at least 1 month allows the selection of patients who will do well with nonoperative therapy. Patients with persistent symptoms and venous obstruction should be offered thoracic outlet decompression. Chronic anticoagulation is not required in these patients. (J Vasc Surg 2000;32:57-67.)

Surgical management of subclavian-vein effort thrombosis as a result of thoracic outlet compression

Background: There is considerable variability and controversy in the current management of subclavian-vein effort thrombosis. The purpose of this study was to determine the long-term effectiveness and the functional outcome of our preferred treatment strategy of early thrombolysis/recanalization and prompt extensive supraclavicular decompression. Patients and methods: Thirty-three patients who ranged in age from 15 to 60 years underwent operative decompression of 34 primary subclavian-vein thromboses, one of which was bilateral. There were 21 patients with acute thrombosis—7 of whom had had prior unsuccessful balloon venoplasty, 1 with stent placement—and 8 patients with chronic/recurrent thrombosis—5 of whom had had 9 unsuccessful prior operations for attempted decompression. Four patients had high-grade symptomatic stenosis and positional occlusion. A supraclavicular approach was used in 32 cases and, in 23 cases, was complemented by an infraclavicular (n = 21) or transaxillary (n = 2) incision. Complete subclavian-vein decompression was achieved by first-rib resection (n = 31), scalenectomy (n = 33), and circumferential venolysis (n = 34). Results: Follow-up was obtained in 30 patients at a mean of 31 months. Twenty of the 21 patients with acute thrombosis had a complete resolution of symptoms with a return to full activity; the other patient was lost to follow-up. Four of the 8 patients with chronic thrombosis reported a mild relief of symptoms but still had limitations of activities of daily living. All of the patients with high-grade symptomatic stenosis with positional occlusion had a complete relief of symptoms and a return to full activity. Conclusion: The optimal management of acute effort thrombosis of the subclavian vein includes anticoagulation therapy, thrombolysis/recanalization, confirmatory positional venography, and early supraclavicular decompression of the subclavian vein. In the patients with chronic subclavian-vein thrombosis and positional venographic evidence of compression of first-rib bypass graft collaterals, the initial anticoagulation therapy should be followed by the surgical decompression of the collaterals. The supraclavicular approach alone or with an infraclavicular incision provides optimal exposure for scalenectomy, total first-rib resection, and circumferential venolysis. (J Vasc Surg 1998;28:777-86.)

Early operative intervention after thrombolytic therapy for primary subclavian vein thrombosis: An effective treatment approach

Purpose: Effective treatment of primary subclavian vein thrombosis focuses on restoration of venous patency, relief of intrinsic stenosis, and decompression of the thoracic inlet. The appropriate method and timing for surgery, however, have not been not well defined. We conducted a study to determine an acceptable treatment approach. Methods: A retrospective review evaluated 11 patients seen at our institution in an 8-year period. Seven patients were male and four were female, with an average age of 30 years (range 15 to 54 years). Two patients who had symptomatic stenosis without occlusion were omitted from the study. All patients with occlusion received urokinase therapy and underwent surgical decompression within 5 days of thrombolytic therapy. Five percutaneous transluminal angioplasties were attempted before operative intervention. Eleven decompressions were performed, including nine first-rib resections and two scalenectomies. Five operative venous procedures, consisting of thrombectomy with patch closure (n = 3) and bypass (n = 2), and seven venolysis procedures were performed. All patients received coumadin for 3 to 6 months after the operation. Results: Urokinase therapy established wide venous patency in nine of the 11 extremities treated, with the remaining two requiring thrombectomy for residual thrombus at the time of operation. One patient who underwent transluminal angioplasty before the operation had rethrombosis, and the remaining four showed no improvement in venous stenosis after the intervention. Eight of nine extremities treated by first-rib resection and one of two treated by scalenectomy were free of residual symptoms at follow-up. Conclusions: Preoperative use of percutaneous balloon angioplasty is ineffective and should be avoided in this setting. Surgical intervention within days of thrombolysis obviates the need for interim oral anticoagulation and enables patients to return to normal activity sooner. (J Vasc Surg 1998;27:1101-8.)